Transcription

1 Professional Indemnity Insurance for Specialist Consultants/Firms Proposal Form

2 Professional Indemnity Insurance for Specialist Consultants/Firms Proposal Form Please read the following carefully before completing this proposal form. To present a clear and unambiguous picture and to ensure that underwriters understand the nature of your risk: An Individual or a Partner, Principal or Director of the Firm/Company must complete the proposal form in ink. All questions must be answered to enable a quotation to be given. Where a question is not applicable to your particular circumstances, please write N/A. If there is insufficient space to answer questions please use an additional sheet and attach it to this proposal form. Completing and signing this proposal form does not bind you, or insurers, to complete this contract of insurance. If this proposal relates to a new business or venture, please complete the questions as far as possible, giving estimated income and information about your anticipated activities. Please provide any standard contract terms, conditions, agreements or letters of appointment, which you have with your clients. 1. (a) Name of Individual or Firm(s) (including any subsidiary requiring cover) (b) Date established (c) Address(es) (specifying who is responsible, if there is more than one location) Postcode (d) Website address (e) Name(s) of any previous Firm(s) requiring cover and the date(s) on which they ceased trading 2. a) Name of Individual, Partner, Principal or Director Age and Qualifications Date Qualified Number of years Practical Experience Please attach detailed CVs 2

3 b) Name of Consultants Age and Qualifications Date Qualified Number of years regularly used Practical Experience Please attach detailed CVs c) Do you require cover for past Partners, Principals or Directors? Yes No If yes, please provide details 3. a) Is any Individual or the Firm admitted to any Association or Trade Body? Yes No b) Has any person been the subject of disciplinary proceedings by any professional body? Yes No 4. Please state the total number of Partners, Principals or Directors: Specialist Staff: Consultants: 5. a) If you are a sole practitioner, please give details of arrangements made in the event of sickness or holiday. 3

4 b) Is this a Part-time occupation? Yes No If yes, please give brief details of your present full-time work. 6. Please clarify the type of work normally carried out, whether consisting of well-established techniques or nature of new and original thought developments, processes or designs employed. State whether and what licensing or similar agreements are in force and the degree to which supervision of them is exercised. 7. a) Have there been any major changes in the activities undertaken during the past twelve months or are any likely to take place in the next twelve months? Yes No b) Is cover required for any activity, now ceased, which is different from those declared, within this proposal form? Yes No 8. Please list by activity the approximate percentage of work carried out in each instance: PLEASE ATTACH A BROCHURE OR ANY `HANDOUT THAT YOU USE. ALTERNATIVELY A COMPREHENSIVELY TYPED EXPLANATION OF THE ABOVE ACTIVITIES (this will enable underwriters to better understand your risk) PLEASE ALSO PROVIDE YOUR STANDARD CONTRACT TERMS AND CONDITIONS 4

5 9. a) Please state the gross fees/turnover received for each of the last three financial years billed to clients and an estimate for the next twelve months. Year UK Worldwide ex USA/Canada USA/Canada 19 Turnover Fees 20 Turnover Fees 20 Turnover Fees Estimate Year UK Worldwide ex USA/Canada USA/Canada 20 Turnover Fees Financial Year ends (Month) b) What percentage of fees is paid to sub-contractors or consultants? 10. a) Please list the three largest contracts undertaken in the last three years: i) ii) iii) b) What is the largest annual income earned from a single client in the last twelve months? In the case of Overseas contracts, please list the countries involved and whether U K or local law applies. Also, please give brief details of the contract(s) and size. 11. Do you or have you ever undertaken contracts involving physical contracting? Yes No If yes, please provide full details 12. a) When Professional Sub-contractors or Specialist Consultants are engaged, have you, in the past, and will you in the future endeavour to ensure that they are appointed directly by and paid by the client? Yes No b) Have you and will you ensure that such persons or firms have entered into a binding contract accepting full responsibility for their own Professional neglect, error or omission and that they carry and maintain in force Professional Indemnity insurance? Yes No 5

6 13. a) If you are a member of a consortium or have entered into a joint-venture agreement, please give details. b) Do you undertake work for or are you associated, either by shareholding or official position, with any company/organisation, where you are in a position to make major decisions? Yes No c) Do you undertake work for or are you associated, either by shareholding or official position, with any company/organisation, where you are in a position to make major decisions? Yes No d) Have any of the Partners, Principals or Directors been a Partner, Principal or Director or been associated with any business that has ceased trading, either voluntarily or compulsorily? Yes No If yes, please give details 14. Do you wish to consider any of the following extensions? Loss of Documents Yes No Unintentional Breach of Confidentiality Yes No Libel & Slander Yes No Unintentional Breach of Copyright Yes No Dishonesty of Employees Yes No Claims arising from Associated Companies Yes No 15. Do you currently have Professional Indemnity insurance? Yes No Expiry date Limit Excess Insurer 6

7 16. Have you ever had any Professional Indemnity insurance cancelled, declined or only written at special terms? Yes No 17. Please state: limit of indemnity required self insured excess 18. a) Do you always require satisfactory written references when engaging employees? Yes No b) Is any Partner, Principal, Director or Employee allowed to sign cheques on their sole signature? Yes No If yes, please give details c) How often are employees who receive cash or cheques, during the course of their duties, required to pay these in? d) How often are checks carried out on all entries in cash books, with all paying-in books, receipts, counterfoils and vouchers being reconciled with bank statements, including the balance of cash and unpresented cheques, independently of employees receiving or banking monies, belonging to the Firm or in trust, on behalf of others? 19. Have you EVER had any claims made against you or know of any circumstances that could or would have resulted in a claim, if cover had been in force? Yes No If yes, please give full details. 7

8 IMPORTANT NOTICE CONCERNING DISCLOSURE It is your duty to disclose all material facts to Insurers. A material fact is one, which may influence an Underwriter s judgement in the consideration of your proposal. If your proposal is a renewal, it is likely that any change in facts previously advised to Insurers will be material and such changes should be highlighted. If you are in any doubt as whether a fact is material or not, you should disclose it. FAILURE TO DISCLOSE could prejudice your rights to recover in the event of a claim or allow Insurers to void the policy. I/We declare that the statements and particulars contained in the proposal are true and that I/we have not misstated or suppressed any material facts. I/We agree that this proposal, together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/We undertake to inform Insurers of any material alteration to these facts occurring before completion of the contract of insurance. However, the duty to disclose material facts continues after completion of this proposal and throughout any period of insurance (and any extensions thereto), upon which this proposal form was used as the basis of the contract of insurance. Date (day) (month) (year) Signature: (Individual, Partner, Principal or Director) Position: A COPY OF THIS PROPOSAL SHOULD BE RETAINED BY YOU FOR YOUR OWN RECORDS Towergate Underwriting and Towergate Underwriting Financial Risks are trading names of Towergate Underwriting Group Limited Towergate House, 77 Leadenhall Street, London EC3A 3DE Tel: Fax: Registered Office: Towergate House, Eclipse Park, Sittingbourne Road, Maidstone, Kent ME14 3EN Registered in England No Authorised and regulated by the Financial Services Authority 2599/186/PF/12.10/11971

Professional Indemnity Insurance for Specialist Consultants Proposal Form Professional Indemnity Insurance for Specialist Consultants Proposal Form Please read the following carefully before completing

Professional Indemnity Insurance for Professional Risks of building and engineering contractors Proposal Form Professional Indemnity Insurance for Construction Industry Professionals Proposal Form Please

Professional Indemnity Insurance for Insurance Intermediaries Proposal Form Professional Indemnity Insurance for Insurance Intermediaries Proposal Form Please read the following carefully before completing

Professional Indemnity Insurance for Marketing, Media and Advertising Proposal Form Professional Indemnity Insurance for Marketing, Media and Advertising Proposal Form Please read the following carefully

Professional Indemnity Insurance for Surveyors and Property Consultants Proposal Form Professional Indemnity Insurance for Surveyors and Property Consultants Proposal Form Please read the following carefully

PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS ACCOUNTANTS PROFESSIONAL INDEMNITY INSURANCE This proposal form must be completed in ink by a Partner, Principal or Director of the Firm or Company.

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR HEALTH & SAFETY CONSULTANTS This proposal form must be completed in black ink by a Partner, Principal or Director of the Company. All questions must be

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ACCOUNTANTS This proposal form must be completed in black ink by a Partner, Principal or Director of the Company. All questions must be answered to enable

INTERSURE INSURANCE BROKERS LIMITED PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ADVERTISING AGENTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ARCHITECTS This proposal form must be completed in black ink by a Partner, Principal or Director of the Company. All questions must be answered to enable

Professional Indemnity Insurance for Accountants Proposal Form Professional Indemnity Insurance for Accountants Proposal Form Please read the following carefully before completing this proposal form. To

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ADVERTISING AGENTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with our most competitive quotation, it

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ACCOUNTANTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with our most competitive quotation, it is important

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ARCHITECTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with our most competitive quotation, it is important

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM Please Note: This is a proposal form for a policy relating to claims made against the Insured during the period of the policy only CLAIMS MADE. Please

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR MEDICAL MALPRACTICE This proposal form must be completed in black ink by a Partner, Principal or Director of the Company. All questions must be answered

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER TO COMPLETION OF THIS PROPOSAL FORM 1) Disclosure - Any material fact must be disclosed to Insurers. - A material fact

AIG Europe Limited Proposer Details Name of Firm(s) Principal Address line one Principal Address line two City and postcode Telephone number Fax number Website address Is the Firm(s) a subsidiary of an

INFORMATION TECHNOLOGY PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER TO COMPLETION OF THIS PROPOSAL FORM 1) Disclosure - Any material fact must be disclosed to Insurers. - A material

Miscellaneous Professional Indemnity Insurance Proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters with

QPI Professional Specialists in Protecting Professions Professional Indemnity Insurance Proposal Form for Accountants IMPORTANT INFORMATION Duty of Disclosure When completing any insurance proposal form

HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM ENGINEERS PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS PROPOSAL FORM: ALL QUESTIONS SHOULD BE COMPLETED IN INK. WHERE A QUESTION IS NOT

Management Consultants Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

PROFESSIONAL INDEMNITY INSURANCE MISCELLANEOUS PROPOSAL FORM GUIDANCE TES This proposal must be completed in ink by a Partner or Director of the Proposer. Please use your headed notepaper to provide full

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR INSURANCE INTERMEDIARIES Howden Insurance Brokers Limited is an official scheme provider of Professional Indemnity for BIBA members Please complete this

Proposal Form This Proposal form must be completed in ink, signed and dated by a Principal, Partner or Director of the Proposer. All questions must be answered and where appropriate not applicable or n/a

Professional Indemnity Insurance Facility for APCC Members Professional Indemnity Insurance Facility for APCC Members PROTEAN RISK is as a specialist insurance broker focused on the needs of the investment

AIG Europe Limited Proposer Details Name of Firm(s) Principal Address line one Principal Address line two City and postcode Telephone number Fax number Website address Is the Firm(s) a subsidiary of an

PEMBROKE SYNDICATE 4000 MISCELLANEOUS ERRORS & OMISSIONS INSURANCE APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY ALL QUESTIONS MUST BE ANSWERED COMPLETELY. DO NOT LEAVE ANY SPACE BLANK. INDICATE

AIG Europe Limited Bailiff and Private Investigators Professional Liability Insurance Proposal Proposer Details Name of Firm(s) Principal Address line one Principal Address line two City and postcode Telephone

CATLIN HONG KONG LTD MISCELLANEOUS PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER REGARDING COMPLETION OF THIS PROPOSAL FORM 1) Disclosure Any material fact

Please answer all questions leaving no blank spaces. If you have insufficient space to complete any of your answers, please continue on your headed paper. This form must be signed and dated by a Partner,

ProJuris Professional Indemnity Professional Indemnity Insurance Proposal. Important information What is a proposal? This proposal tells us information, which we need to know in order to decide whether

IT Professionals Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

MISCELLANEOUS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your

Media Professionals Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

Professional Indemnity Insurance Design and Construct Industry Proposal Form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block

Professional Indemnity Insurance for Miscellaneous Professions Proposal Form Important Notice 1. This is a proposal for a contract of insurance, in which Proposer or you / your means the individual, company,

ACCOUNTANTS PROFESSIONAL INDEMNITY PROPOSAL FORM Centry Gothic Please read the following questions carefully and answer them all providing additional information where required. Should you require more

Professional Indemnity Proposal Form Business & Management Consultants This form does not apply to: IT Consultancy. Please see the IT Professions proposal form GUIDANCE NOTES Completing your proposal form

IMPORTANT POINTS Please ensure all questions are answered fully, where there is insufficient space please supply information on a separate sheet. The questions must be answered to the best of your knowledge

Proposal Form Professional Indemnity Insurance (Information Technology Consultants) ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed

BDB (UK) Limited 40 Lime Street, London EC3M 7AW PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS PROPOSAL FORM 1 GUIDANCE NOTES This proposal must be completed in ink by a Partner or Director of the Proposer.

INDEPENDENT FINANCIAL ADVISORS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER TO COMPLETION OF THIS PROPOSAL FORM 1) Disclosure - Any material fact must be disclosed to Insurers.

PEMBROKE SYNDICATE 4000 ACTUARIES ERRORS AND OMISSIONS INSURANCE APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY ALL QUESTIONS MUST BE ANSWERED COMPLETELY. DO NOT LEAVE ANY SPACE BLANK. INDICATE

DICKSON MANCHESTER Charity and Association Liability Proposal Form Proposal form for Insurance effected through Dickson Manchester & Co Ltd A SUBSIDIARY OF HCC INSURANCE HOLDINGS, INC. Member of the General

Professional Indemnity Proposal Form Project Management GUIDANCE NOTES Completing your proposal form Please complete all questions in full using the Additional Information section or separate sheets where

INSURANCE BROKER AND INTERMEDIARIES PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER TO COMPLETION OF THIS PROPOSAL FORM 1) Disclosure - Any material fact must be disclosed to Insurers.

Professional Indemnity Proposal Form Architects GUIDANCE NOTES Completing your proposal form Please complete all questions in full using the Additional Information section or separate sheets where necessary.

Consulting Engineers Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

Professional Indemnity Insurance for Accountants Proposal Form Professional Indemnity Insurance for Accountants Proposal Form Please read the following carefully before completing this proposal form. To

Notice:Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any amendments thereof; You are to disclose in this application, fully and faithfully, all the facts which you know or ought

Professional Indemnity Proposal Form Surveyors GUIDANCE NOTES Completing your proposal form Please complete all questions in full using the Additional Information section or separate sheets where necessary.